Outline

Definition & mechanism of shock.

Consequences of Shock.

How to diagnose shock?

Classification of Shock.

Causes of various types of shock

Basic principles in management of shock.

Shock

Reduction of effective tissue perfusion leading to cellular and circulatory dysfunction

Shock

Medical emergencies if unrecognized or inadequately treated will result in

high mortality

ShockShockReduced Perfusion

BrainBrain

Decreased mental status

Myocardial Depression

KidneyKidney

Oliguria

LiverLiver

Increased liver

enzymes

LungLung

Hypoxemia

Pheripheral CirculationPheripheral Circulation

Hypotension

Heart Heart

Shock

The aim of perfusion is to achieve adequate Cellular Oxygenation

This requires

Red Cell Red Cell

Oxygenation Delivery To Tissues

Fick Principle

Fick Principle

Air’s gotta go in and out.Blood’s gotta go round and round.Any variation of the above is not a

good thing!

Shock

Red Cell Oxygenation

1. Oxygen delivery to alveoli

Adequate FiO2

Patent airways

Adequate ventilation

Shock

Red Cell Oxygenation

2. Oxygen exchange with blood

Adequate oxygen diffusion into blood

Adequate RBC capacity to bind O2

– pH– Temperature

Shock

Red Cell Delivery To Tissues

1. Adequate perfusionBlood volume

Cardiac output– Heart rate– Stroke volume

Conductance– Arterial resistance– Venous capacitance

Shock

Red Cell Delivery To Tissues

2. Adequate RBC mass/Hgb levels

Adequate RBC mass

Adequate Hgb levels

Adequate RBC capacity to unbind O2

pH

Temperature

Consequences of Shock

Inadequate tissue perfusion:

Poor cellular Shift from aerobic

Oxygenation to anaerobic

metabolism

ANAEROBIC METABOLISM

GLUCOSE METABOLISM

2 LACTIC ACID

2 ATP

HEAT (32 kcal)

Glycolysis: Inefficient source of energy production; 2 ATP for every glucose; produces pyruvic acid

AEROBIC METABOLISM

6 O2

GLUCOSE

METABOLISM

6 CO2

6 H2O

36 ATP

HEAT (417 kcal)

Glycolysis: Inefficient source of energy production; 2 ATP for every glucose; produces pyruvic acid

Oxidative phosphorylation: Each pyruvic acid is converted into 34 ATP

Anaerobic Metabolism

Occurs without oxygenoxidative phosphorylation can’t occur without oxygen

glycolysis can occur without oxygen

cellular death leads to tissue and organ death

can occur even after return of perfusion organ dysfunction or death

InadequateCellularOxygenDelivery

AnaerobicMetabolism

InadequateEnergyProduction

MetabolicFailure

LacticAcidProduction

MetabolicAcidosisCELL

DEATH

Ultimate Effects of Anaerobic Metabolism

Shock

Markers Of Hypoperfusion

↑ Serum Lactate

Metabolic acidosis

Hypotension

Maintaining perfusion requires:

Adequate Volume

Normal Cardiac Function

Normal Vessels

Failure of one or more of these causes shock

Shock Syndromes

● Hypovolemic Shock- Blood volume problem

● Cardiogenic Shock- Blood pump problem

● ObstructiveShock- Filling Problem

● Distributive Shock- Blood vessels problem

Hypovolemic Shock

Loss of Volume

Blood loss

▪ Trauma▪ Non-traumatic

VaginalGIGU

Fluid loss - Dehydration- Burns- Diarrhea- Vomiting- Diuresis- Sweating

Third space lossesPancreatitisPeritonitisBowel obstruction

ShockShockSign and

Symptoms

BrainBrain

Decreased mental status

KidneyKidney

Oliguria

LiverLiver

Increased liver

enzymes

LungLung

Hypoxemia

Pheripheral CirculationPheripheral Circulation

HypotensionCold Clammy skin

Key Issues In Shock

Recognize & Treat during compensatory phase

Best indicator of resuscitation

effectiveness = Level of Consciousness

Restlessness, anxiety, combativeness = Earliest signs

of shock

Hypovolemic Shock Management

Goal: Restore circulating volume, tissue perfusion & correct cause

• A B C• Two large bore IV lines/central line• Fluids / Blood & Products /vasopressors Target arterial BP – SBP ≥ 90 mmHg - MAP ≥65 mmHg.• Bladder catheter• Arterial Cannulation

Key Issues In Shock

Tissue ischemic sensitivity

Heart, brain, lung: 4 to 6 minutes

GI tract, liver, kidney: 45 to 60 minutes

Muscle, skin: 2 to 3 hours

Resuscitate Critical Tissues

First!

Consequence Of Volume Loss:

15%[750ml]- compensatory mechanism maintains cardiac output

15-30% [750-1500ml]-decreased BP & urine output

30-40% [1500-2000ml] -profound shock along with severe acidosis

40-50% - refractory stage

Shock

Cardiogenic Shock = Pump Failure

MyopathicM ICHFCardiomyopathy

ArrhythmicTachy or bradyarrhythmias

Mechanical Valvular Failure

HOCM

Cardiogenic Shock

History : Chest pain, Palpitations,SOBRHD,IHD

Physical exam:Signs of ventricular failureHeart : Murmurs,S3,S4

Cardiogenic Shock

Treat rate, then rhythm, then BP

Correct bradycardia or tachycardia Correct irregular rhythms Treat BP

↑Cardiac contractility (inotropes)– Dobutamine, Dopamine

Distributive Shock

Inadequate perfusion of tissues due to mal-distribution of blood flow.

(blood vessels problem)

Cardiac pump & blood volume are normal but blood is not reaching the tissues.

Distributive Shock

1. Septic Shock

2. Anaphylactic Shock

3. Neurogenic/Vasogenic(spinal

cord)

4. Endocrinologic

Septic Shock management

A B C

Assist ventilation & Augment Oxygenation

Monitor Tissue perfusion-

Restore Tissue perfusion-

IV Fluids, Vasopressors

Identification & Eradication of septic foci

Specific Therapies

-

Neurogenic Shock

Patient supine; lower extremities elevated

Avoid Trendelenburg

Infuse isotonic crystalloid

Maintain body temperature

Anaphylactic ShockAntihistaminesCorticosteroidsEpinephrine Isotonic fluid titrated to BP ~ 90 mmHg

Obstructive shock

Impaired diastolic fillingCardiac tamponade

Constrictive pericarditis

Tension pneumothorax

Increased ventricular afterload

Pulmonary embolism

Obstructive Shock

Treat the underlying causeTension Pneumothorax

Pericardial Tamponade

Anticoagulation

Isotonic fluids titrated to BP w/o pulmonary edema

Control airwayIntubation

Key Issues In Shock

Falling BP = LATE sign of shock.

BP is NOT same thing as perfusion.

Pallor, tachycardia, slow capillary refill = hypoperfusion, until proven otherwise.

Shock Management

Avoid vasopressors until hypovolemia ruled out, or

corrected

Squeezing partially empty tank can cause ischemia, necrosis of

kidney and bowel